Application to Register with a General Medical Practitioner - Under 16

You should only send this form if you are sure that you are eligible to join this practice.
Sending this form will NOT automatically register you with the surgery.
Your details will be held at the surgery for a limited period of time.
Sending this form does NOT guarantee or even imply that you will be accepted onto the practice register

Registration Form (Under 16)

Personal Details

Your Child’s Details

Title

NHS Number Optional

First Name

Middle name(s) Optional

Surname

Gender

Any previous names child known by: Optional

Date of Birth

Address

Street Address Address Line 2 City Postcode

Contact Number

Town and Country of Birth

Ethnicity

Previous Home Address

Street Address Address Line 2 City Postcode

Previous GP

Name of previous GP (if applicable) Optional

Previous GP address (if applicable)

Street Address Optional Address Line 2 Optional Town or city Optional

Parent or Guardian Details

Your Name

Relationship to Child

Address

Street Address Address Line 2 City Postcode

Home Telephone Optional

Mobile Telephone

Do you consent to be contacted by SMS?

Yes

Family details (Parents names, addresses and contact numbers if different from child) Optional

Is there anyone else responsible for caring for your child (eg relative)?

Yes Optional

No Optional

Their name, address and contact number if different from the child. Optional

Please inform us if the situation changes so we can update the contact details for your child.

Communication Needs

Language

What is your childs main spoken language? Optional

Do you need an interpreter?

Yes Optional

No Optional

Communication

Does your child have any communication needs?

Yes Optional

No Optional

Please specify

Hearing aid Optional

Lip reading Optional

Large print Optional

Braille Optional

British Sign Language Optional

Makaton Sign Language Optional

Guide dog Optional

Learning Disability

Does your child have a Learning Disability?

Yes Optional

No Optional

Medical History

Family history Optional

Please list any illness that runs in your family

Have any close family members suffered from any of the following:

Heart disease Optional

High blood pressure Optional

Stroke Optional

If you ticked any of the above please state relationship to child Optional

School details (if applicable) Optional

Please provide name and address of current Nursery or School (if applicable)

Has your child had any serious illnesses or operations?

Yes Optional

No Optional

If yes, please provide details and approximate dates Optional

Does your child have a disability or chronic condition?

Yes Optional

No Optional

If yes, please provide details Optional

Please tell us of any allergies or sensitivities below Optional

Immunisation History

Which Vaccinations has your child had?

Age: 8 weeks

1st Diphtheria, Tetanus, Pertussis Optional

1st Polio Optional

1st HIB Optional

1st Rotavirus Optional

1st Meningitis B Optional

Date of 1st Diphtheria, Tetanus, Pertussis

Date of 1st Polio

Date of 1st HIB

Date of 1st Rotavirus

Date of 1st Meningitis B

Age: 12 weeks

2nd Diphtheria, Tetanus, Pertussis Optional

2nd Polio Optional

2nd HIB Optional

1st Pneumococcal Vaccine Optional

2nd Rotavirus Optional

2nd Meningitis B Optional

Date of 2nd Diphtheria, Tetanus, Pertussis

Date of 2nd Polio

Date of 2nd HIB

Date of 1st Pneumococcal Vaccine

Date of 2nd Rotavirus

Date of 2nd Meningitis B

Age: 16 weeks

3rd Diphtheria, Tetanus, Pertussis Optional

3rd Polio Optional

3rd HIB Optional

Date of 3rd Diphtheria, Tetanus, Pertussis

Date of 3rd Polio

Date of 3rd HIB

Age: 12 months

HIB / Men C Booster Optional

3rd Meningitis B Optional

MMR (Measles, Mumps, Rubella) Optional

2nd Pneumococcal Vaccine Optional

Date of HIB / Men C Booster

Date of 3rd Meningitis B

Date of MMR (Measles, Mumps, Rubella)

Date of 2nd Pneumococcal Vaccine

Age: 3 Years 4 Months

MMR Booster (Measles, Mumps, Rubella) Optional

Pre-School Booster Diphtheria, Tetanus, Pertussis, Polio Optional

Date of MMR Booster (Measles, Mumps, Rubella)

Pre-School Booster Diphtheria, Tetanus, Pertussis, Polio

Current Medication

Please check and include as much information about your child’s current medication below.

If they have a previous repeat medication list please provide this to us and they may need a medication review appointment: Optional

Is there any other information you think we need to be aware of?

Details: Optional

Electronic Prescribing

If you would like your child's prescriptions to be sent electronically, please provide details of the pharmacy you would like to use: Optional

Parent or Guardian Signature Optional

Please provide your full name

Sharing Your Childs Health Record

Do you consent to your GP Practice sharing your child's health record with other organisations who care for you?

Yes (recommended)

No – Never

Do you consent to your GP Practice viewing your child's health record from other organisations that care for you?

Yes – (recommended)

Your Childs Summary Care Record (SCR)

Do you consent to your child having an Enhanced Summary Care Record with Additional Information?

Yes – (recommended)

Parent or Guardian Signature

Please provide your full name

Date Optional

Email Optional

This field is for validation purposes and should be left unchanged.